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Will caffeine really stop your headache? Can you eat chocolate without feeling worse? Certain foods may play a big role in your chronic migraines. This is your chance to learn how to recognize your triggers and take control.

Join in as our expert guests discuss how foods can influence migraine frequency and severity. They will explain how to track your triggers by keeping a food diary, get tested for food allergies and develop a meal plan that helps keep migraines at bay. Plus, they’ll debunk the myths around the usual food trigger suspects, like alcohol, caffeine and sugar.

As always, our expert guests answer questions from the audience.

Announcer:

Welcome to this HealthTalk webcast. Before we begin, we remind you that the opinions expressed on this webcast are solely the views of our guests. They are not necessarily the views of HealthTalk, our sponsors or any outside organization. And, as always, please consult your own physician for the medical advice most appropriate for you.

Now here's your host.

Rick Turner:

With the holidays come endless amounts of food and celebrating that can include chocolate fudge, red wine and fruit cake. Certain foods can play a big role in your chronic migraines, leaving you in a lot of pain and alone in a dark room for the holidays - not where you want to be.

Hello and welcome to “Which Foods Fuel Your Migraines.” I'm Rick Turner. In this webcast, our expert guest will discuss how certain foods can influence migraine frequency and severity. We'll hear how to identify food triggers through the process of elimination and how to develop meal plans that keep your migraines at bay. We'll also get to the bottom of the role caffeine might play in seeming to help - or actually trigger - your migraines.

Joining us on the program today is Dr. David Buchholz, author of “Heal Your Headache: The 1 2 3 Program for Taking Charge of Your Pain,” a must have book for anyone suffering from headaches. For 14 years, Dr. Buchholz served as director of the Neurology Consultation Clinic at Johns Hopkins University School of Medicine. He has authored more than 150 scientific publications and given over 450 invited lectures, and has been featured on “Good Morning America,” “Larry King Live” and National Public Radio’s “Morning Edition.” And he joins us.

Welcome, Dr. Buchholz.

Dr. David Buchholz:

Hi, Rick. It's a pleasure to be with you.

Rick:

Our pleasure to have you. Dr. Buchholz, in your book you talk about a migraine control center in the brain. What is that? Start by telling us how and where a migraine begins in the brain.

Dr. Buchholz:

The idea of a control center is more of a concept than a reality that we've been able to precisely identify, but the concept is very powerful. I like to think of a control center in the brain that governs the mechanism of a migraine and determines its level of activity. It's really what goes on in this control center, which is receiving a steady stream of triggers that are getting stacked up there and matched against your personal migraine threshold - it's that that determines how much you're going to suffer from headaches or be able to prevent them.

Rick:

But you say it's not necessarily a specific physical location in the brain?

Dr. Buchholz:

If it is, I imagine that it's in the hypothalamus, which is a part of the central brain, deep-seated. It turns out that many of the triggers that contribute to the activation of migraine have access to that part of the brain. For example, chemicals that are derived from things we eat and drink circulate in the bloodstream, and that particular part of the brain is not protected by the blood brain barrier that shields most of the brain from exposure to circulating chemicals. The hypothalamus in contrast has access to these circulating chemicals, so it makes it a likely candidate to be the site of trigger exposure.

Rick:

Right. So one of these chemicals somehow activates a migraine in your brain. How does the brain then cause pain? How does it make your head hurt or cause the other symptoms associated with migraine?

Dr. Buchholz:

Once migraine is triggered in the control center and we'll talk more about just how that happens but once this mechanism becomes activated, a cascade of events occurs involving different pathways in the brain, which utilize a variety of neurotransmitters. Ultimately, a center in the brain stem becomes activated as part of this process. That area in the brain stem gives rise to nerves that exit from the central nervous system and are distributed all around the head, behind the face as well as in the neck and surrounding regions. The upper back and shoulder areas are all part of the territory of migraine.

These nerves, once they become activated as this process unfolds, release chemicals from their endings, and the chemicals cause nearby blood vessels to become swollen and inflamed. That's the basis of the pain that you feel when you have a headache. There are sensory nerves that detect the presence of that blood vessel swelling and inflammation, carry that information back in the brain, and translate that information into your miserable experience of pain.

Rick:

So is it fair to say that everyone has this type of control center in their brain, but people with migraines just have an extra sensitive version of it?

Dr. Buchholz:

Precisely. This mechanism, for whatever reason, is built into our brains by nature, but what distinguishes some people as headache sufferers and others as not is the following: Partly it's a matter of your individual trigger load, and that relates to issues such as being a woman between teenage and menopausal years and having the influence of cyclical estrogen, which is a trigger that men don't have to bear. It’s also based on your dietary habits, your sleep patterns, your stress level, certain medications you might be on; all of those things make one person's trigger level different than another's. And of course for each of us the trigger level varies from day to day.

But an even more essential difference between the headache sufferer and the non-headache sufferer is the person's ability to tolerate triggers up to a point. In other words, we all have a certain ability to tolerate triggers, but we all have a limit to that tolerance or a threshold, if you will. People who are not headache sufferers have comfortably high thresholds, so they can stack up a whole bunch of triggers before they ever reach that point and experience headache. Whereas headache sufferers - and this is largely hereditary - have relatively low migraine thresholds, so it doesn't take a whole lot of triggers to cross that line.

Rick:

The focus of this program today is the holidays and the food and drink we consume. How do different foods contribute to migraine in this whole trigger process, Dr. Buchholz?

Dr. Buchholz:

It's by means of certain chemicals in these food items that for whatever reason are among the many triggers that tend to add up and activate migraine. And mind you, there are lots of other triggers, like stress and not getting enough sleep, and hormones and aspects of the weather, such as falling barometric pressure, and certain medications like birth control pills and so on. But what makes food triggers special is, first of all, for most of us they actually constitute a major component of the total trigger loads that we carry. Of course, that's a great opportunity because you could thereby substantially reduce your total trigger level - aiming to keep it below your threshold - through dietary modification.

Rick:

What percentage are you talking about?

Dr. Buchholz:

It varies from person to person, but I would say for many people half or more of the trigger load they carry seems to be related to dietary items. And I say that because through the process of dietary modification, many people are able to substantially reduce their level of headache activity.

Rick:

So then are all food triggers created equal? That is to say, will the same food impact everyone the same way?

Dr. Buchholz:

No. Everyone is different. There is a certain prioritization to these triggers, and we'll talk about the specific ones later on. I group a half-dozen or so items toward the top of the list, and then others seem to be lesser triggers, but my observation is that many people find that some of the items near the bottom of the list of potential culprits are the major problem items for them. So there are ways, as we'll discuss, that every individual can ferret out what his or her triggers might be, but we're all different.

Rick:

Then what's the difference, Dr. Buchholz, between a food trigger and an allergic reaction?

Dr. Buchholz:

Well, there's a superficial resemblance in that you're exposed to something and it has an adverse affect upon you. But strictly speaking, what distinguishes an allergic reaction is that it's an overreaction of your body's immune system to something, whereas these dietary triggers don't act through the immune system. They act, as I explained, by feeding into the migraine control center in the brain along with lots of other nondietary triggers.

And I would point out that some people have the mistaken impression that they can sort out their dietary triggers through allergy testing - either blood tests or skin tests - and unfortunately that's not possible.

Rick:

So what is the best way to recognize your food triggers?

Dr. Buchholz:

The best way is to eliminate the potential culprits as thoroughly as you can. No one can ever do it perfectly, but if you can unload 90 percent of your dietary triggers, you're going to make a major dent in your total trigger load. Through that you gain control of your headache problem to a degree where you're satisfied, and at that point you then carefully experiment by reintroducing these items, or at least the ones that you particularly desire or that are just really inconvenient to have to avoid; you figure out what you can get away with and what you can't.

Rick:

Okay. Let's take a look at some of the common culprits. We have a good sense of how food triggers work. What are the most common triggers, Dr. Buchholz?

Dr. Buchholz:

I would put caffeine at the top of the list. And part of the problem with dietary triggers for most headache sufferers is that they're difficult to recognize. Caffeine is a prime example. The effect of caffeine, temporarily, is to constrict blood vessels such that if your head is beginning to hurt, as the blood vessels around it become swollen because migraine has become activated and its end product is blood vessel swelling, well, caffeine may seem to take the edge off that impending headache. Or if you're used to a certain caffeine intake and you decrease or stop it, you're likely to have temporary withdrawal headaches; all of the above contributes to the illusion, the common, popular belief that caffeine is friendly to headaches.

Rick:

Right.

Dr. Buchholz:

The truth is the opposite. It's really your enemy, and the problem is that you need to get through whatever transition may be involved with withdrawal; that can be a few days or a few weeks, where you may actually have a rise in headaches temporarily in order to benefit from abstinence.

The problem is that your blood vessels are tending to swell in the first place, and you are subjecting them to a constricting influence like caffeine. The natural state of those vessels over time becomes one of greater and greater swelling. The equilibrium of these blood vessels changes as they're subjected to repeated temporary artificial constriction. So you're promoting the swelling of blood vessels in the long run by exposing yourself to caffeine.

Rick:

So it might be a short term cure or at least a help, a treatment for your migraines, but it's going to do more damage over the long term?

Dr. Buchholz:

Precisely. That's exactly right. And of course people are often confused about hearing that caffeine can be a migraine trigger, and yet they look at the bottle of Excedrin Migraine that they're taking and there's caffeine in it. This doesn't make any sense. Well, it does in the way that I just explained.

Rick:

Right.

Dr. Buchholz:

Before we talk about the other food triggers that are important, let me just say that in addition to caffeine being confusing, other dietary triggers are often not readily recognized, and this is really important for listeners to understand. One reason for that is because the time between when you consume a dietary trigger and when it has its effect can be delayed not just hours but even a full day or two. And you can understand that that would make your recognition of that item as a trigger difficult.

Rick:

Sure.

Dr. Buchholz:

Another reason is that dietary triggers act with apparent inconsistency in many cases. That is, sometimes you might have to admit that you drink red wine or you eat chocolate and you seem to get a headache after that, but you're glad to observe that on other occasions you can drink red wine or eat chocolate and you seem to get away with it. And so you reassure yourself that you really don't need to bother to avoid red wine or chocolates if you want to avoid headaches, because after all, if those were triggers you'd get a headache every time.

The problem behind that reasoning is that it's overly simplistic and it ignores the presence of a multitude of other triggers that vary from day to day. So if you're well-rested and not stressed out and it's not around your period and the weather is stable, you may be able to drink red wine, eat chocolate, and get away with it. Whereas if you're sleep-deprived and stressed at work and your period is approaching and the barometric pressure is dropping as a storm approaches, and you eat chocolate, you're going to give yourself a headache. Well, and chocolate...

Rick:

…is next on the list.

Dr. Buchholz:

Yeah. I put that right under caffeine. It's a shame because it's awfully darn tasty, but it is a major trigger. And keep in mind that all of these dietary triggers act in a dose related fashion. That is, a little bit of chocolate - a nibble or a couple of chips in a cookie - you might get away with, whereas a whole fudge bar or some chocolate mousse cake, that may be too much of a dose for you to handle on a given day.

Rick:

Right.

Dr. Buchholz:

Monosodium glutamate (MSG) is a huge problem. It's an additive intended to make commercially processed or restaurant food taste better, and it can do that. However, it backfires for many people as being a very potent migraine trigger. And it's much more than just Chinese restaurant food. It's a lot of other restaurant food, not just various Asian cuisines. A lot of chain restaurants use MSG to jack up the flavor quotient of their meals; and then all sorts of things you might buy in the supermarket: frozen meals, particularly lo cal items which would not taste like much if they didn't put MSG to jazz them up; all sorts of packaged snack foods, particularly when they have a salty aspect; the various boxed and canned items. So it's tricky because MSG is often disguised under aliases.

Rick:

That's what I was going to ask, if it's on the label.

Dr. Buchholz:

Unfortunately not. Sometimes it is, but often it's labeled in some alias fashion - for instance, hydrolyzed vegetable or soy protein or autolyzed yeast extract. There's a number of other suspicious ingredients that may indicate the presence of MSG. “Natural flavors” is one way that MSG can be legally labeled, and that's because the food industry has convinced the FDA (Food and Drug Administration) that, Hey, MSG - what can be more natural? It's basically produced by the fermentation of molasses. It's ultimately derived from corn syrup or from sugar beets, and so that sounds pretty natural - and so we can call it “natural flavors,” and you'd never realize that you're getting a dose of MSG.

Rick:

Oh, that's pretty tough to identify then.

Dr. Buchholz:

It is.

Rick:

Beyond MSG, what are the other common food triggers?

Dr. Buchholz:

Processed meats that contain nitrites and sometimes MSG too, but things like, oh, processed lunch meats, bacon, sausage, hot dogs, certain dairy items and particularly aged cheese. The more cheese ages the more it accumulates the chemical tyramine (a natural substance formed from the breakdown of protein as food ages), which is a major common thread among these dietary triggers. So cheeses on the young end of the spectrum, for instance cottage cheese, cream cheese, American cheese - the not-so-yummy ones in other words, you might be able to get away with, whereas a really good bleu cheese or aged cheddar are much more likely to be problematic. Also other dairy products, particularly yogurt, whether it's plain yogurt or frozen yogurt, and buttermilk can be problems.

Rick:

Okay.

Dr. Buchholz:

Nuts and legumes - so peanuts, peanut butter, tree nuts - they're major triggers for many people. And then, unfortunately, alcohol, and it's similar to cheese. There's a spectrum there too. There are some alcoholic beverages that are not so much headache triggers, vodka probably being the best tolerated of all, and then others like red wine, dark liquors and champagne, which are much more common culprits.

And the reason is not their alcohol content, although it is true that ethyl alcohol is a chemical trigger for migraine, but it seems that what distinguishes certain alcoholic beverages from others on the spectrum is the level of so called congeners. Those are other chemicals that are present in various forms of alcohol that give those items their distinctive color and flavor. Chemicals, for instance, related to tyramine and tannins and sulfites, are sometimes added to preserve wine and so on. And so you may be able to pick and choose your way on the spectrum, but obviously it's all dose related things, so if you drink too much of anything you're more likely to suffer in the morning. And by the way, what we commonly consider hangovers are indeed migraine experiences.

Rick:

Really?

Dr. Buchholz:

And also, alcohol does a double-whammy on you because it's a diuretic, so you have a net fluid loss if you're not drinking something else along with the alcoholic beverage, like water or juice. And then of course dehydration is another triggering influence.

Then there are some items that you wouldn't imagine. Things like red wine or chocolate may be kind of obvious as potential culprits, but how about, for instance, citrus fruits?

Rick:

Really?

Dr. Buchholz:

Who would think that that glass of orange juice in the morning or that grapefruit or some pineapple or lemonade could be a trigger? But it is, for many people, very potently so. People are different, and some people - if they try to reintroduce dietary items - get away with this or that, and others don't. I'm constantly surprised to hear people being able to reintroduce many of the major offenders without recurrence of headaches, but then when they try to drink orange juice in the morning that seems, for them, to be a killer.

Rick:

Wow.

Dr. Buchholz:

Bananas are another one, and certain vegetables, particularly broad beans that have a high level of tyramine; onions, particularly raw onions, and then soy products. That's another spectrum item, where the more you process soy products the more you break down the protein and you thereby liberate glutamate, which is equivalent to monosodium glutamate. And soy beans have a natural level of tyramine in them, too.

Rick:

Wow. Okay.

Dr. Buchholz:

And then finally, I would mention the artificial sweetener NutraSweet or aspartame, although some of the others, particularly sucralose or Splenda, don't seem to be a contributor to headaches.

Rick:

Well, that's quite a list you just went through, Dr. Buchholz, but I imagine even beyond that list there are certain foods triggers for individuals that are not included there.

Dr. Buchholz:

That's true. For instance some people find that certain items that are naturally rich in glutamate, like tomatoes and mushrooms and milk, can be culprits for some people. My approach is that you've got to draw the line somewhere or the list just becomes so lengthy and unwieldy that no one is ever going to begin to address it. So I normally don't steer people away from those items, but I would advise anyone who observes from their personal experience that something like, let's say, strawberries seems to be a trigger for them. Well, if you're a headache sufferer I would stay away from them.

Rick:

Right. And then beyond the food triggers themselves you mention several others that are common triggers: hormones, stress - what else is on that list that is a common non-food trigger?

Dr. Buchholz:

Well, I like to divide triggers into two basic categories: the ones that you're pretty much stuck with, and the ones that you can do something to avoid. Ones that you're pretty much stuck with would include, for instance, aspects of the weather, barometric pressure, heat or humidity, or temperature changes. Situational stress that's a normal part of life would be another example of a relatively unavoidable trigger. And cyclical estrogen.

And then more importantly, thankfully, there are lots of avoidable triggers. Diet is a major component of that, but certain medications too. Earlier I mentioned birth control pills and other forms of hormonal contraception. This would also be true of hormone replacement therapy (HRT). Some of the popular antidepressants, the SSRIs (Selective serotonin reuptake inhibitors), and SNRIs (Serotonin-norepinephrine reuptake inhibitors), which people use for anxiety and depression, they can be triggers for some people. The popular reflux drugs, the so called proton pump inhibitors, may be triggers. In many of these instances there are alternative medications that you can substitute. For example, one of the older reflux drugs, the so called H2 blockers, would not be a contributing factor.

And then there's sleep deprivation, which many people suffer from because they have insomnia and can't sleep well, but lots of people inflict themselves with sleep deprivation. They stay up too late having to get up early in the morning. They get five or six hours of sleep per night because they're just so busy that they don't give themselves time to get enough sleep, which for most of us is eight hours.

Rick:

Yes.

Dr. Buchholz:

And it's a major addition to your headache trigger load that you might be able to do something about by making sleep more of a priority.

Rick:

Dr. Buchholz, in your book you call “rebound” the real culprit, and state that it is the greatest potential impediment to headache control. In fact, avoiding rebound is step one in your 1 2 3 program. What exactly is rebound? And why is it so damaging to migraine sufferers?

Dr. Buchholz:

Rebound is this: You have a headache. You want to get rid of it because it's awful and you want to be able to function, so you're likely to look for relief in a painkiller, either over the counter or by prescription, and hopefully that drug temporarily relieves the headache you already have. But many of these drugs make your next headache more likely. And so in that way they backfire, and over time you develop a vicious cycle of increasing headaches and escalating use of the very drugs that are causing you to have more headaches, although you don't realize that that's what's happening.

One way of thinking of rebound is similar to what I explained about caffeine. A lot of the drugs that provide temporary headache relief constrict blood vessels - that's their mechanism of action - but that tends to produce more swelling of blood vessels in the long term. The bottom line is that many chronic headache sufferers are inadvertently feeding their headache problems through the use of these pain killers.

It's also key to understand that if you're in a rebound mode, as lots of chronic headache sufferers are, you will not respond to preventive measures such as dietary modification or preventive medication. And that's the cardinal reason why there are so many individuals out there who consider themselves failed headache patients or who are labeled with that unfortunate term by their doctors. It's not that they have an untreatable headache problem at all. It's that the problem of rebound has not been adequately addressed.

Rick:

They're in a vicious cycle.

Dr. Buchholz:

Absolutely.

Rick:

So what drugs should we watch out for?

Dr. Buchholz:

Be careful of over the counter products that contain caffeine - Excedrin and lots of other brands - and over the counter products that have decongestant ingredients. Those would be the sinus medications that a lot of people take on an as needed basis for what they think of as their sinus headaches, which as it turns out in most cases are actually forms of migraine.

And then there are the popular prescription drugs these days, especially the triptans (a group of tryptamine-based drugs used in the treatment of migraine and cluster headaches). There are a number of them: Imitrex (sumatriptan), Relpax (eletriptan HBr). And many listeners, I'm sure, are very, very familiar with these drugs, and they can be extremely effective in the short run, but when you use them more than you should and I would draw the line tightly at no more than two days per month, not per week, per month you're likely to slide into a rebound state and become less and less responsive to preventive measure.

Rick:

Let's talk about step two in your program, then: reducing their trigger level. Before you can avoid triggers though, you have to identify them, and you, unlike a lot of experts, do not recommend keeping a food diary. So how would someone go about identifying which foods are the culprit for them?

Dr. Buchholz:

First let me explain why I don't recommend the diary approach. I don't recommend it because of the reasons I explained. Even if you keep track, you're not likely to really see the connections clearly. You're instead likely to simply document the apparent inconsistency of your response to dietary triggers and wrongly conclude that those aren't triggers because if they were triggers, they'd be consistent.

I find a more effective approach is to eliminate the whole range of potential dietary items, and once you get your headaches under control which may require additional steps, it would certainly require eliminating any rebound problem you may have, and you may have to address certain medications that you're taking that are contributing to your headaches and so on but once you get under control, then you carefully reintroduce dietary items one at a time to see what you can get away with or what you can't. And people can ultimately achieve a balance of comfortable, livable dietary restriction on the one hand and adequate headache control on the other.

Rick:

And once you eliminate a food that is a trigger for you, can you expect immediate relief or does it take a while to adjust?

Dr. Buchholz:

Oh, it takes a while. It takes a while, first of all, to get good at the diet, to be able to read labels and figure out how to prepare food at home and how to order in restaurants. That takes time. Typically it takes at least a few weeks if not a couple of months to get good at the diet. And it's usually in the range of a couple of months - minimum - that it takes to really begin to see substantial improvement.

So my general recommendation is to give the diet a careful two months minimum before you then decide whether you need to take further steps, which we're going to talk about later - step three in my program. And even if you succeed at two months by following the diet alone and eliminating any rebound problem you may have, I'd stick with the diet another two months - that is a total of four months - before you consider liberalizing that. And the simple reason is that you have to have a long enough period of headache control to serve as an enduring memory to guide you back to control if and when you stray from the path and wind up, for example, cheating too much on the diet and giving yourself headaches. If you don't have a solid four month block of headache control to remember, you're less likely to ever get yourself back on the right road.

Rick:

Establish a baseline, as it were.

Dr. Buchholz:

Yes.

Rick:

Now, you talk about MSG as a trigger and how it's often hidden in foods; is this process of elimination that you're describing, Dr. Buchholz, especially problematic for those hidden triggers?

Dr. Buchholz:

Yes, and MSG is the primary culprit there. There is a whole list of aliases for MSG. There are a couple dozen of them. We talked about some of the major ones. We don't have time to list them all now, but looking out for those aliases is one way to do it. Be particularly wary of certain types of restaurants and of food that has heavy breading or certain sauces with a savory character - that is often a signal for hidden MSG. It's tricky business, and in my view it's pretty hard, if you live in the real world, to completely avoid MSG. But again, if you can reduce your exposure by 90 percent, that's a big chunk out of your trigger load.

Rick:

I can imagine that one of the biggest challenges for our audience would be following a restricted diet, especially around the holidays. I mean, who doesn't love chocolate? Of course everybody does. And it might be tough to hear that you can never have a glass of wine or a piece of fudge again without experiencing severe pain. But I seem to be hearing from you, Dr. Buchholz, that there is a way to still enjoy these foods without the pain.

Dr. Buchholz:

Yeah, absolutely. And sometimes people will choose to enjoy these foods and suffer the pain, and actually I don't have a problem with that. In a funny way, once my patients get under control, I actively invite them to experiment carefully and thoughtfully with the diet. And even beyond that, I invite them to inform me of the cheating that they do, because I need to know what's going on, and I never scold anybody for it. And I sometimes find myself saying, you know, I actually think it's healthy to cheat on the diet here and there because it gives you a sense that you're not totally constrained and you have some breathing room. And if you get away with it, that's great, and if you don't, okay, then maybe it reinforces that that's an item that’s actually worth avoiding. It's kind of a win win situation. But the point is you've got to follow the diet carefully enough to get your headache problem under control before you can play around with it.

Rick:

Then reintroducing triggers you mentioned, is it just a matter of everything in moderation?

Dr. Buchholz:

There's a couple of different ways to do it. The way that most people do it, realistically, is they kind of cheat on a sporadic basis, like when they're at somebody's house or at a party or they go out to a restaurant. And they may get away with it, and they keep that in mind for the next time they're tempted. Or they may not get away with it, and that might reinforce avoidance. But you can do it more scientifically. You can pick an item and reintroduce it on a daily basis for a week, and by the end of that week, if you've tolerated it - given the delay effect that we talked about and given the good-day bad-day effect in terms of your load of other triggers - you might be able to judge that that item is okay. But yes, moderation is key because it's all dose related.

Rick:

This brings us to step three: raising your threshold. And Dr. Buchholz, can you tell us what you mean by raising your threshold, and how does that work?

Dr. Buchholz:

Just to recap. So step one is to avoid or eliminate rebound. Step two is to do what you can to reduce your trigger load, which is largely the diet that we've been discussing, maybe getting rid of certain medications and getting enough sleep. And then step three is to raise your threshold, which is to increase your limit of tolerance for migraine triggers so that you can stack up more of them without crossing the line and activating migraine. And that can be accomplished in two ways. One is natural and the other requires some pharmaceutical help.

The natural way is to exercise. And it turns out that if you do cardiovascular exercise three or four a week, or more if you're a real hero, and you do 30 or 45 minutes of something vigorously cardiovascular, you stimulate production of endorphins in your brain, and those are natural preventive agents. They block the pathway of migraine, and by doing so, by inhibiting the output of migraine, which is blood vessel swelling around your head, it's like having your threshold elevated so that you have more tolerance for triggers.

But there's also a way of doing that that involves the use of certain prescription medications that have been discovered largely by accident to be effective for migraine prevention. They block the pathway, thereby raising the threshold. And these include certain antidepressants - not the newer ones, but the older ones, the tricyclic antidepressants; certain blood pressure medicines, particularly calcium channel blockers and beta blockers; and certain seizure medications - two, primarily: Depakote (valproic acid) and Topamax (topiramate).

But I would always say that this is step three, and this is the last step that for many people turns out to be an unnecessary step if they properly take steps one and two.

Rick:

We have a lot of questions coming in for you, Dr. Buchholz. The first one is from Jennifer. She's in Washington, D.C. Jennifer says, “My doctor says I have sinus headaches, but they always seem to get worse when I eat certain things. Can foods trigger sinus pressure?”

Dr. Buchholz:

Yes, through the mechanism of migraine. I commented earlier that much or perhaps most of what people consider their sinus headaches, or what doctors diagnose as so called sinus headaches, are really forms of migraine. When you think about it, it turns out the linings of your nose and sinuses are chock-full of blood vessels, so that would seem to be a favorite target site for migraine to strike. That is, when migraine becomes activated and produces swelling of blood vessels around your head, well, that's a ripe target. And so you get pressure, fullness, congestion, pain behind the face as a result of the swelling of blood vessels generated by migraine.

But because of the way we're sort of trained by conventional wisdom to think of that as some kind of a sinus issue, misdiagnosis is routine. And sometimes this is self-diagnosis, and people go to the drugstore, buy a decongestant - Sudafed (pseudoephedrine), Tylenol Sinus (acetaminophen/phenylephrine), you name it - and take it. And guess what? They get temporary relief, because that ingredient constricts the painfully swollen blood vessels. But before long, it's making them rebound and making the underlying problem of migraine get worse and worse.

Otherwise, through doctors mislabeling migraines as so called sinus infection or sinusitis, people wind up getting treated with needless antibiotics or all sorts of other drugs, or even undergoing unnecessary sinus surgery. So if you're a person who suffers from what you think are chronic sinus headaches, rethink the diagnosis and think migraine.

Rick:

Cynthia from San Diego writes, “I always thought I had a chocolate allergy because when I eat a lot of chocolate I get sick to my stomach and a bad headache. How can I determine the difference between an allergy and a migraine trigger?”

Dr. Buchholz:

Well, in the case of chocolate you don't need to. It's a migraine trigger, and what you're describing is a perfect migraine experience because migraine often produces not only headache but also nausea, sometimes vomiting, and other gastrointestinal disturbances. So there's no allergy issue here. It's migraine, pure and simple.

Allergies to other substances may be determined through allergy testing - either blood tests or skin tests - but migraine triggers can't be determined that way, as we discussed.

Rick:

Okay. Bob in Portland, Oregon writes, “Sometimes wine causes migraine, sometimes not. Does this mean it's a trigger, and why doesn't wine always cause a migraine if it is a trigger?”

We touched on this earlier.

Dr. Buchholz:

It's whether you have enough other triggers stacked up at the time. It's also a question of how much wine you drink. It's a matter of what kind of wine you drink. It's a matter of what else you may be eating or drinking along with it - the cheese at the party or chocolate or nuts or the little hot dogs - all sorts of other things that are major migraine triggers.

Rick:

And individuals, I understand, can just be more vulnerable at certain times to a trigger.

Dr. Buchholz:

Well, that's true, but it's reflective of that individual's trigger load that they're carrying: how well they've been sleeping lately, how stressed out they are, where they are in the menstrual circle, what the weather is up to, and all of that.

Rick:

Right. Andrew in Vermont writes, “Can dietary supplements trigger migraines? I take a product called Juice Plus+ that is dehydrated fruit, and you mention that as a potential trigger. Could this be causing my headaches?”

Dr. Buchholz:

It's an excellent question from Andrew. It depends on what the fruit is, and it depends on whether there are any preservatives. Certain fruits - as I mentioned, citrus, bananas, raisins and other dried fruits that have sulfites to preserve them - are all potential triggers. I don't know the ingredients of this product.

There are other nutritional supplements that I would caution listeners about - particularly protein items, protein powders or energy bars. Those are headache bombs. They're full of glutamates, because the protein that has been processed to be put into those items is broken down, and thereby glutamate, which is one of the amino acids that makes up protein, is released. And so you have to be very careful of those kinds of items. Also, soy products that people sometimes use to supplement their diet are problematic. Be careful.

Rick:

Okay. Are there certain dried fruits, Dr. Buchholz, you would consider safe?

Dr. Buchholz:

Yes. Any dried fruit other than raisins that's not preserved with sulfites should be fine.

Rick:

Okay. Veronica in San Diego writes, “I know smoking is not a food, but can it trigger a migraine?”

Dr. Buchholz:

It's interesting. You know, you would think that cigarette smoking or tobacco smoke would, for the inhaler, be a trigger, but it doesn't really seem to be for most people. However, having said that, for many migraine sufferers who aren't smokers, the presence of tobacco smoke can be a huge trigger for them. And that is actually true of not only smoke in the air but also other odors or scents that you might inhale. For instance, strong perfumes or walking into a shop that has lots of scented candles or strong soaps and those kinds of things, or a scratch and sniff ad or perfume ad in a magazine, or cleaning products - those kinds of things, for many people, are huge triggers. They are different than dietary triggers in one key way, and that is that odors, as triggers, tend to be in your face. That is, you breathe the item, smell it, and get a headache almost immediately, whereas dietary triggers are more stealthy because of their delay.

Rick:

Yeah. We talked about the effect that caffeine has on the vessels in your brain or around your brain. What does nicotine do?

Dr. Buchholz:

Well, it too has a vasoactive effect, and it turns out that it actually has some relaxing effect in the brain, but despite its vasoactive properties it just doesn't seem to be an important trigger for most headache sufferers. Marijuana similarly. Some people say that it helps, particularly to relieve a headache that they already have. Now, I'm not advocating it, but...

Rick:

Okay. Fair enough.

Sandra from Nashville, Tennessee writes, “How can I identify my child's headache triggers when I can't watch her all the time?”

Dr. Buchholz:

Hmm. You know, I see children and teenagers often in my practice, and it impresses me very much how well most kids can learn to adjust their behaviors so that they don't have to suffer from headaches and miss school, and I'm speaking especially of dietary behavior. What I do is try to educate the kids and their parents as to the whole process of migraine, and specifically the way that dietary items feed into it. And if you think about the list, a lot of them are pretty much the staples of kids' diets. You've got sodas and chocolate and pizza and other cheeses and peanut butter and orange juice and hot dogs, you know.

Rick:

Sure.

Dr. Buchholz:

So there's a rich opportunity for kids to unload those items and eat healthier, and it's easier to do these days than it might have been in the past, particularly given choices at schools and so on. So the mother's right that you can't always be there overseeing what your child does, but you can help to educate your child to make the right choices.

Rick:

And they want that headache to go away too.

Dr. Buchholz:

Sure. Who wants to suffer?

Rick:

Sure. Glen in Greenbelt, Maryland writes - this is about sleep, because we talked about how sleep deprivation can be a trigger - but Glens says, “Can getting too much sleep cause a migraine?”

Dr. Buchholz:

Yes, in one sense, and that is if you haven't been getting enough and then you oversleep to compensate. Absolutely. And it's one of the several reasons why people get weekend headaches. They don't get enough sleep during the work week. They sleep in on Saturday or Sunday morning to catch up, and they wake up with a whopper headache, and it's a double-whammy. It's the accumulation of the sleep deprivation throughout the week, which is of course what's driving them to oversleep anyway, and then it's the change in the sleep wake schedule that seems to be a disturbance that acts as a migraine trigger.

Of course, other factors contributing to weekend headaches include that you normally get up early in the morning and you drink a cup of coffee or two, and you don't do that or do that as early on the weekends, so you suffer from caffeine withdrawal. And of course the solution is not to wake up earlier on the weekends and drink caffeine, but to get away from it during the week.

And then it may be what you're doing Friday or Saturday night, in terms of your alcohol consumption and staying up too late. And sometimes, interestingly - we tend to think that stress is a headache trigger, and it can be in the acute stage when you're faced with stress, but it's also often the letdown after stress, such as weekends or when you go on vacation, that seems to breed headaches.

Rick:

Tom from Chicago says, “Is there a way to test for migraine triggers the way you do for allergy triggers? For example, maybe a blood test?”

Dr. Buchholz:

That would be awfully handy, but there isn't. So the only way to test is really from your own personal experience - that is, getting your headaches under control by avoiding dietary triggers and then carefully reintroducing items and making observations as to their effect.

Rick:

Not something you can see under a microscope.

Dr. Buchholz:

Unfortunately.

Rick:

No. Janet from Sacramento says, “You're talking a lot about foods that trigger migraine, but are there foods or specific diet that helps migraine?”

Dr. Buchholz:

That would be great. Unfortunately, it's true only to a limited extent. First of all, make sure that you drink enough water or some other healthy liquid so that you don't get dehydrated; eat on a regular schedule and don’t go too long between meals, because that's a big trigger.

But unfortunately, no, there aren't really any foods that you can point to as being protective. There is modest evidence that certain supplements can help, such as magnesium, feverfew, vitamin B2, Coenzyme Q10 and butterbur extract. These are all herbal or supplementary type things. But in terms of individual food items, there is not really a protective diet available.

Rick:

Well, a follow-up question to that from Troutville, Massachusetts: “Is it true that using only olive oil will reduce your migraines?”

Dr. Buchholz:

I'm not aware of that.

Rick:

Nice try, though.

Rick:

Another question, “Is there a good way to track all my triggers - not just food triggers, but the other ones like PMS (premenstrual syndrome), sleep patterns and that sort of thing?”

Dr. Buchholz:

Well, that's where diaries come in, and as you mentioned earlier, Rick, there are experts who advocate that approach. To a degree, some of it just seems to me to be useless information. For instance, if you find that your headaches tend to be more likely when a storm is approaching, as the barometric pressure is dropping, what are you going to do about that?

Rick:

Right.

Dr. Buchholz:

Move to Arizona? I don't think it's really of practical value. I would say that the important thing is to do what you can to identify triggers that you can do something about.

Rick:

Right. Those that are under your control.

Dr. Buchholz:

Yes. And you know, okay, arguably a diary may be of some limited benefit in that respect, but one of the reasons I don't like diaries is my whole goal is to eliminate headaches as problems in people's lives, and somehow I've seen too many people who hold onto diaries as a sort of way of life even after their headache problem is actually under pretty good control. And it's like, you know, let go. You don't have this problem anymore and you don't need to keep a record of it.

Rick:

It becomes a crutch that they continue to lean on?

Dr. Buchholz:

It's a habit that I think at some point becomes counterproductive.

Rick:

Cindy from Oakland writes, “Chocolate seems to make me feel better when I have my period, but it also triggers my migraines. Is there a way to balance the benefits versus the risks of causing a migraine?”

Dr. Buchholz:

Well, the less the better, obviously, in terms of the amount of chocolate that you might eat. There is unquestionably, for many women, a heightened chocolate craving around their periods, and so of course that's just unfortunate because then you're tempted to indulge at just the wrong time. And yes, of course chocolate can make you feel good in many ways. There's a school of thought that some of the chemicals in it actually have an effect on the brain so as to increase pleasure. But I would say if the headache is a problem, it's just not worth paying the price.

Rick:

Right. Related to that same issue, Dr. Buchholz, do you ever recommend hormonal therapy?

Dr. Buchholz:

I don't. As a general rule, and a really good, strong general rule, it's fuel on the fire. It's rocket fuel on the fire of migraine. The logic behind hormonal therapy, certain types of birth control pills for instance, is often that, Well, there seems to be a correlation between my headaches and where I am in my cycle. They're worse around my period or at ovulation, so maybe if we manipulate that, we can improve the situation. Well, it's a good example of it not being wise to fool around with Mother Nature, because as much as you may succeed in flattening the menstrual headache spike through certain forms of hormonal therapy, you tend to give rise to an overall increased level of headache activity. So I would not recommend that.

Rick:

Do we know how hormones actually work in triggering a migraine?

Dr. Buchholz:

I don't. I admit readily that I don't understand really how any of these items work. I don't understand how falling barometric pressure feeds into the migraine control center on any kind of cellular or molecular level. I don't understand how stress or sleep deprivation or dietary items or certain medications all add up, but they do. Through some mechanism that we just don't understand yet, they do all contribute to the likelihood of migraine, and that's the important thing.

Rick:

Right. We have another question from Brett in San Francisco. Brett writes, “You mentioned over the counter (OTC) drugs are dangerous for rebound. Why don't they place a warning label on these OTC drugs that says overuse can cause rebound headaches?”

Dr. Buchholz:

Well, I guess because then they wouldn't sell as many.

Rick:

There's your short answer.

Dr. Buchholz:

Yes.

Rick:

Michelle from San Antonio says, “You mentioned all of my comfort foods. Are there any that are safe for my migraines?”

Any special comfort foods?

Dr. Buchholz:

Oh, sure. The list of foods that you can eat and drink without contributing to the likelihood of migraine is vastly longer than the list of foods that you should avoid. Yeah, there are all sorts of snack foods, carbohydrate rich foods, and fatty foods that you can indulge in to your heart's desire and not suffer migraines from them. So it's not restrictive. The diet is not restrictive in that way.

May I just briefly go back to Brett's question about the medications not being labeled?

Rick:

Yes.

Dr. Buchholz:

I was being glib, but there's more to it.

There's a general tendency for both headache sufferers and their doctors to have heads buried deeply in sand when it comes to this whole rebound issue. People just don't want to face the realty that rebound is a huge problem. Why not? Well, because headache sufferers don't want to hear that they have to give up their Excedrin (acetaminophen, aspirin and caffeine) or their Fioricet (butalbital, acetaminophen and caffeine) or their Imitrex (sumatriptan) because that's the crutch that they're depending on to get through the day. Doctors don't want to take the time to tell patients what patients really don't want to hear: You know, I'm going to have to cut back on this medication that I'm prescribing that you're using as a quick fix. So everyone sort of goes merrily along as though these drugs aren't causing the huge problem that they are. And of course the pharmaceutical companies are quite happy with that situation.

Rick:

Okay.

Jerrod from Los Angeles writes, “I basically eat water and lettuce, and I still have terrible migraines. I've cut everything out of my diet and still the headaches are there. What now?”

Dr. Buchholz:

An important concept is that while for some people the diet may be the successful means of headache control, for other people it's only a part or a piece of the solution.

Rick:

You mentioned about 50 percent overall, perhaps.

Dr. Buchholz:

Yes. And so in this case, perhaps there are some other triggers on board that might be unloaded with respect to certain medications that can contribute to migraine or sleep deprivation. I'd question whether there might be a rebound problem. And if all of that is addressed and headaches continue to be a problem, then that's a case where preventive medication or step three in my program would be the logical final step to raise the threshold, because I think in this gentleman's case it's probably very low to begin with.

Rick:

You mentioned earlier that exercise can often help you raise your threshold for migraine triggers, and Charlie from Redding, California says, “I always get a migraine after I exercise. How common is that?”

Dr. Buchholz:

It's very common, and it's another one of these paradoxes that confuse people. Even for the individual for whom exercise seems to be an immediate trigger or an acute trigger, it's still helpful to exercise on a regular basis, because if you can get into that groove, you will help to raise your threshold and you'll be better protected. So let's see, how can you get over the hump? Well, obviously you deal with any rebound problem you have. You do what you can to reduce your trigger level through dietary modification.

And then when it comes to your attempt to exercise, think about this. First of all, assuming that you don't have a problem tolerating anti-inflammatory medication such as ibuprofen, you can take a dose of that - up to as much as 800 milligrams, which you can get over the counter - half an hour or an hour before you exercise. That can help to protect you. You can always repeat it four hours later if you have to. Keep yourself well-hydrated. Exercise in a cool environment and warm up slowly.

And think about the type of exercise that you're doing. Weight lifting in particular can be a trigger, but when it comes to cardiovascular stuff, sometimes people find that running on a treadmill jars their head and contributes to the likelihood of headache, whereas using a different type of equipment that has a smoother motion, such as an elliptical trainer or stationary bike, may be better tolerated.

Rick:

One final question, a quick one from Mark in North Carolina, “I recently became a vegan and for the first time starting experiencing migraines. Do you think there's a connection?”

Dr. Buchholz:

I do. I do. Various diets, sometimes certain vegan diets or sometimes the low-carbohydrate, high-protein, South Beach, Atkins-type diet, steer people towards cheese and soy products and nuts and processed meats, and winds up breeding headaches. So yes, I do believe there's a connection.

Rick:

And with that, we're just about out of time. But before we go, Dr. Buchholz, I'd like to get final thoughts. What would you like to leave our listeners with today?

Dr. Buchholz:

The simple message is that I don't believe anyone needs to suffer from headaches. I really believe that anyone, by doing the right things, can gain control. You've got to restrict your use of rebound-causing drugs, do what you can to reduce your trigger level, and if necessary you can add preventive medication. But the point is you don't need to suffer.

Rick:

All right. Dr. Buchholz, the author of “Heal Your Headache: The 1 2 3 Program for Taking Charge of Your Pain.” Thanks very much for joining us.

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